As a member of the North American Registry of Midwives (NARM) Board of Directors, I will be taking these statements back for review and look forward to having the opportunity to respond as the agency that oversees credentialing of Certified Professional Midwives (CPMs).
We are at a remarkable moment in time, with seemingly increased attention and opportunities for improvement in maternity care. May these statements serve as a platform for action in all that we consider in the year ahead. I look forward to hearing what our entire community has to say in reaction to these statements.

HOME BIRTH CONSENSUS SUMMIT STATEMENTS

The following statements of common ground reflect the shared commitments of the individuals who participated as delegates to the Home Birth Consensus Summit at the Airlie Center in Warrenton, Virginia from October 20-22, 2011. These statements do not represent the position of any organization or institution affiliated with those delegates.

STATEMENT 1

We uphold the autonomy of all childbearing women.

All childbearing women, in all maternity care settings, should receive respectful, woman-centered care. This care should include opportunities for a shared decision-making process to help each woman make the choices that are right for her. Shared decision making includes mutual sharing of information about benefits and harms of the range of care options, respect for the woman’s autonomy to make decisions in accordance with her values and preferences, and freedom from coercion or punishment for her choices.

STATEMENT 2

We believe that collaboration within an integrated maternity care system is essential for optimal mother-baby outcomes. All women and families planning a home or birth center birth have a right to respectful, safe, and seamless consultation, referral, transport and transfer of care when necessary. When ongoing inter-professional dialogue and cooperation occur, everyone benefits.

STATEMENT 3

We are committed to an equitable maternity care system without disparities in access, delivery of care, or outcomes. This system provides culturally appropriate and affordable care in all settings, in a manner that is acceptable to all communities.

We are committed to an equitable educational system without disparities in access to affordable, culturally appropriate, and acceptable maternity care provider education for all communities.

STATEMENT 4

It is our goal that all health professionals who provide maternity care in home and birth center settings have a license that is based on national certification that includes defined competencies and standards for education and practice.

We believe that guidelines should allow for independent practice, facilitate communication across providers and care settings, encourage professional responsibility and accountability, and include mechanisms for risk assessment.

STATEMENT 5

We believe that increased participation by consumers and multi-stakeholder groups is essential to improving maternity care, including the development of high quality home birth services within an integrated maternity care system.

STATEMENT 6

Effective communication and collaboration across all disciplines caring for mothers and babies are essential for optimal outcomes across all settings.

To achieve this, we believe that all health professional students and practitioners who are involved in maternity and newborn care must learn about each other’s disciplines, and maternity and health care in all settings.

STATEMENT 7

We are committed to improving the current medical liability system, which fails to justly serve society, families, and health care providers and contributes to:

• inadequate resources to support birth injured children and mothers;
• unsustainable healthcare and litigation costs paid by all;
• a hostile healthcare work environment;
• inadequate access to home birth and birth center birth within an integrated health care system, and;
• restricted choices in pregnancy and birth.

STATEMENT 8

We envision a compulsory process for the collection of patient (individual) level data on key process and outcome measures in all birth settings. These data would be linked to other data systems, used to inform quality improvement, and would thus enhance the evidence basis for care.

STATEMENT 9

We recognize and affirm the value of physiologic birth for women, babies, families and society and the value of appropriate interventions based on the best available evidence to achieve optimal outcomes for mothers and babies.

As an advocate for US midwifery and women’s health, I recently had the opportunity to be temporarily lifted out of the trenches of our national battle for access to midwifery care.  As an Observer member of the Midwives Alliance of North America (MANA) delegation to the International Confederation of Midwives (ICM) Council I was given the opportunity to attend the 4-day meeting of the ICM Council at which historic decisions were made for the future of midwifery across the globe.  As a Congress [conference] Delegate, sent by my partners in Private Practice to network and learn about charting requirements and global issues as we continue to design and develop software for midwives, I was able to gain a perspective on the work that we do in the trenches.  Trenches that become so deep at times that we can no longer see the field or a “vision” of what it would look or feel like to no longer be digging.

The importance of a cohesive vision for any movement can sometimes be overlooked when we are shoveling “dirt” that seems to be piling back into our trench faster than we can move it out.  For a country like the US with a mainstream maternity model that is antagonistic to midwifery, the vision becomes very narrow and more of a battle strategy as we fight for the survival of our profession and the integrity of normal birth.

As a midwife who has been entrenched for more than 15 years in the consuming work of battling over birth in the US, the vision articulated by ICM sounded at first to me like so many organizational visions…too broad and ambitious to be realistic.

“ICM envisions a world where every childbearing woman has access to a midwife’s care for herself and her newborn.”  ICM Vision Statement

As those of us involved in organizational work know, what follows a vision is generally a mission, or purpose for organizing:

ICM’s Mission-To strengthen member associations and to advance the profession of midwifery globally by promoting autonomous midwives as the most appropriate caregivers for childbearing women and in keeping birth normal, in order to enhance the reproductive health of women, and the health of their newborn and their families.

Sounds great, but how does a vision and mission like that translate into anything but a cheering squad while we keep up our digging? Especially when you consider that the steps each member association or country would need to take to reach this common goal would be unique and wrought with different challenges. When the digging of the trench nearby inadvertanly throws more dirt into our own, it can lead to internal turf battles and stuggles over principles and purpose. In the United States where this has happened among midwives too many times to count, how can we come together on the steps to take and why should we spend the time trying?

We should come together because mothers and babies are dying at an alarming rate in most of the world. As an American midwife who cares for a predominately healthy, white, middle-class population in a community with access to multi-levels of maternity care, attending a global midwifery conference in a country with maternal mortality rates that are 14 times that of the US was sobering. [1] The paradox of the overuse of medical interventions being a driving force for midwifery in the US with the lack of access to vital, life saving interventions for most of the world’s mothers driving the promotion of midwifery globally is as significant as it is startling.

The Big Picture

In 2008, ICM reflected on its mission and then took steps to address maternal mortality as a primary issue.  By strengthening midwifery in developing countries that face severe issues of mortality and morbidity for mothers and babies, the ICM hopes to move closer to its vision of a midwife for every mother. One symbolic and tangible step was to plan for it’s first ever conference in Africa, specifically sub-Saharan Africa which bears a huge percent of the global burden of maternal and newborn death.

Rebecca Ullman is a certified nurse midwife from Oregon state. She retired from 23 years in a hospital based private practice and traveled to Niger to work with midwives.  Sitting with her at dinner in a café in Durban, South Africa, I was educated on the reality of the high stillbirth rate as an everyday occurrence for midwives, women and families in the developing world.

“While there is always joy in delivering babies, in Niger, that joy is mixed with the sadness and grief that is all too prevalent when childbirth becomes dangerous for mothers and babies because of poor health conditions and poverty.  During my three weeks in Niger, I delivered more stillborn babies than live ones.  We can only imagine the toll that puts on health workers, women, their families, the community and the nation.”

During a presentation about charting and clinical assessment using the WHO partograph, I learned that a typical provider/patient ratio on a labor unit is 3 to 25 in Ghana. Constancia Atachie, Prinicipal Nursing Officer with the Ghana Ministry of Health described conditions in a typical hospital where she worked and conducted research.

“You are literally running from bed to bed, sometimes carrying a new baby under your arm as you race to the operating theatre with another woman. Babies keep coming and you never stop until your shift ends and you do it all again the next day.”

Access to midwifery care is a big issue for us in the US, but access to any care at all is the bigger issue for most of Africa and the developing world.  As we dig in our trenches dedicated to development of the midwifery profession in the US, we need to understand that not only could our efforts be contributing to a more cohesive vision for global midwifery, but also our resources could be shared in ways that we can’t even imagine unless we are listening to the voices of midwives from across borders and oceans.

First Steps on a Path to a Vision

At ICM, Debbie Pulley, CPM, shares information at the MANA Booth with midwives from Sierra Leone.

It was with these images in my mind that I looked to the steps toward the vision being presented by the leadership of ICM at this Congress.  ICM is stepping up to lend its voice in a powerful way to the World Health Organization (WHO) and the United Nations Population Fund (UNFPA) in their efforts to promote midwifery care as a means to reduce maternal mortality.  The voice is coming in the form of a set of Global Standards, Competencies, and Tools that were developed and designed to guide the leaders of the world in the development, implementation, and promotion of midwifery in their countries.

ICM sees these core documents as “pillars” of its global effort to provide high quality, evidence-based health services for women, newborns, and childbearing families. These “pillars” were developed over the last 3 years by expert Task Forces and were adopted by the Council of Delegates in Durban last month. They include:

• Updated Essential Competencies for Basic Midwifery Practice
• Global Standards for Midwifery Education and Companion Guidelines
• Global Standards for Midwifery Regulation
• and a new tool for strengthening Midwifery Associations, the Member Association Capacity Assessment Tool (MACAT).

US Delegates to ICM Council in Durban. Holly Powell-Kennedy, ACNM President, Melissa Avery, ACNM Past President, Diane Holzer, MANA Past President and Geradine Simkins, MANA President.

In the months to come, US midwives will be having important conversations about the impact of these standards on our models of midwifery and our current and future efforts to move forward as part of this new vision.  There is much to digest and reflect upon, but some immediate highlights of challenges and triumphs from the documents include the separation of nursing from midwifery, autonomous regulation, and access to training and education that allows for a scope of practice that honors the central role between mother and midwife and the primary care relationship.

Though some of the standards might cause a struggle for many US midwives to support, if we can understand the context for the inclusion it may become easier to keep a shared vision for the future.  Since we are not in a position to imagine a system that could allow for autonomous regulation or access to adequate midwifery education for direct entry midwives in all 50 states, it makes it hard for us to embrace documents that set these kinds of standards for our profession. When we read that the basic skills of a midwife should include things like HIV treatment, pharmacologic augmentation of labor, and pharmacologic pain relief in labor, we can’t help but wonder how this would relate to midwives who provide care in out-of-hospital settings in the US. As we review these documents together we must keep in mind two important things:

1. In most of the developing world, midwives do not have a higher-level provider to refer to in their community.  Referrals and transfers of care take place over hours of travel, and often there is not time or resources to make the trip.  These standards will be invaluable tools for those countries that are in the process of establishing midwifery as a profession through internationally funded projects. Whatever the midwives are trained to do will be the extent of the care most women and babies in the world will receive.
2. These standards are a vision, not a mandate.  We have an opportunity to lend our voices to the ongoing development of guidance and companion documents for each of the standards.  The council was told by outgoing ICM President, Bridget Lynch, “These are living documents.  Take them into your communities.  Understand them, live with them, and bring back your thoughts to the next Congress (2014 in Prague!).”

Digging our trenches
Playing on the beach as a kid, my brother and I used to dig holes in the sand around our castles.  As we dug our trenches, we aimed our digging for each other.  We had to dig to the same depth and start our turn towards the same spot at the same time.  I still remember the funny thrill of getting closer and closer with our arms until we finally broke through and I felt his digging fingers wiggling at the tips of mine.  We would join hands inside our own trenches and thrill at the ocean waters now flowing back and forth between our projects.

Watching other countries touching fingertips as they merge their visions within their own systems created a bit of a longing for me and a new perspective about the unique challenges we face here in the US.  In the context of Canada, New Zealand, and even most developing countries, we really have an incomparable health system. In fact, in the context of these documents it might be fair to say that we have no health system.  We are unique in our array of 50 different regulatory bodies that create different definitions, designations, and limitation for all types of midwives.  Canada has a health system that provides for health care for all of is citizens. New Zealand has no malpractice insurance issues because health providers can’t be sued in that country.  We are a “high-resource” country with models of care that are more in line with “low-resource” countries in terms of a lack access to quality care for all of our citizens.

Looking to ourselves and visioning our future for US midwifery
Midwifery has been fighting for survival for more than 100 years in the US.  This has resulted in a significant lack of access to training in a model of care that we all agree needs to be preserved and resurged as standard for all maternity providers to integrate and utilize.  We don’t have enough midwives to train the workforce needed. The result is that we have aspiring midwives spending years and countless dollars learning to be nurses before they can become midwives or leaving the country to gain training in out of hospital birth in foreign context and cultures.  How will we integrate those experiences for young midwives as they return from Haiti, Africa, and Indonesia?  How will we move forward with our vision to unify US midwives and grow our profession while still maintaining the integrity of our foremothers efforts to keep birth normal by keeping it simple?  How can we reconcile our converging priorities and unique challenges with the rest of the world?

If we want to be part of the global vision, the first step is in understanding it.  When we can appropriately place ourselves in the global context, we not only gain tools to understanding our unique obstacles and challenges, but we also discover opportunities for strengthening our purpose and our profession. Taking time to read through the ICM core documents should be a priority for all practicing midwives and midwifery advocates in the US.  Alongside these documents, the newly released UNFPA report, The State of the World’s Midwifery, Delivering Health, Saving Lives gives the much-needed global context to understanding the ICM vision.

Complete Lunar Eclipse

Witnessing the full lunar eclipse over the Indian Ocean was a symbolic moment for many of us. A reminder to be humble, to remember that there are greater forces at work, and that we all share one magestic world. The Road to Durban was a worthwhile trip but it will be the journey home that will prove to be most important step towards uniting midwives around the world.

1. Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Wang M, Makela SM, Lopez AD, Lozano R, Murray CJL. Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5. The Lancet. 2010 Apr 12; 375:1609–23.

Sunrise over the Indian Ocean. Durban, South Africa. June 14 2011

I recently had the opportunity to travel to South Africa as part of a delegation for the Midwives Alliance of North America as an Observer to the International Confederation of Midwives (ICM) Triennial Council meeting. I had the unique privilege of listening and learning about the organizational processes that unfold as midwifery leaders from over 50 member countries meet and work together to move midwifery forward on the global level. The Council business meeting preceded the Congress, which was an historic conference of over 3000 midwives from as far as Afghanistan and as near as Zimbabwe.  As the first ever ICM Congress held in Africa, and with over 1000 midwives from South Africa alone in attendance, the milestones, themes, message, and vision were focused on the greatest threats to our global society: maternal and infant mortality and the contributing factors that lead to it.

Part 1: Is Freedom a Theory of Relativity?

The start of my journey to Africa included a layover in the heart of the empire that gave birth to the former colonies of my homeland and my destination. The irony of the unintentional connection to have a visit in London at the start of a journey towards new understanding about the connections between women in all cultures was highlighted by our stumbling upon a global phenomenon in support of women happening in Trafalgar Square. While the Sluts Rally [1], an international series of protests spawned from the negligent comments of a Canadian police officer regarding the relationship of proper dress code and sexual assault, may seem like a frivolous feminist effort, there is significant connection when we understand that cultural colonization continues it’s global creep.

Sluts Rally, Trafalgar Square, London, UK June 11, 2011

How can a rally in Trafalgar Square that seems on the surface to be demanding the right of women to wear their underwear in public without harassment mean something to women in South Africa who live in a country that leads the world in rape crimes?

Rape Statistics: South Africa, US, and UK

• It is estimated that a woman born in South Africa has a greater chance of being raped than learning how to read. [2] One in three of the 4,000 women questioned by the Community of Information, Empowerment and Transparency said they had been raped in the past year.[3]
• More than 25% of a sample of 1,738 South African men from the KwaZulu-Natal (Durban) and Eastern Cape Provinces admitted when anonymously questioned to raping someone; of those, nearly half said they had raped more than one person, according to a non-peer reviewed policy brief issued by the Medical Research Council (MRC). [4]
• According to United States Department of Justice document Criminal Victimization in the United States, there were overall 191,670 victims of rape or sexual assault reported in 2005. 1 of 6 U.S. women has experienced an attempted or completed rape. From 2000-2005, 59% of rapes were not reported to law enforcement.[5][6]
• According to a news report on BBC One presented in 12 November 2007, there were 85,000 women raped in the UK in the previous year, equating to about 230 cases every day. According to that report one of every 200 women in the UK was raped in 2006. The report also showed that only 800 persons were convicted in rape crimes that same year.[7]

It is indeed sobering to realize that many of our common bonds with the women of South Africa are in the shared threats of sexual assault, exploitation, and access to quality maternity care. It would seem that the ties that bind are less of an issue of resource and more of an issue of society.  A lack of priority for the issues that face women in the world crosses country and culture.

International Confederation of Midwives Walk to Durban
This sense of international despair for our future was transformed in a rally of hope as thousands of midwives from all over the world arrived in South Africa and joined together in a Walk to Durban in an effort to highlight the focus of the World Health Organization (WHO) and the United Nations Population Fund (UNFPA) on midwives as the key to delivering health and saving lives of women and babies everywhere. We may be the key, but the lock can only be turned with significant support for access to midwifery education, autonomous midwifery regulation, and strong professional associations that will serve to bring back the ancient art of providing safe and effective maternity care with each woman at the center of the system that serves her.

Today is Independence Day in the United States.  A day to celebrate the hard earned freedoms that we generally take for granted.  For those of us who live in the safety nets of protected environments, let’s take a moment to envision our nets spreading to women all over the world.  Envision a world where all childbearing women are safe from rape, HIV, postpartum hemorrhage, fistulas, sepsis, and death.  Every woman can stand together for this most inalienable human right.

Up Next:

ICM, An Organization With a Vision

____________

Resources:

[1] http://wearechangetoronto.org/2011/04/10/solidarity-slut-walk-london-ontario/

[2] http://news.bbc.co.uk/2/hi/africa/1909220.stm

[3] http://news.bbc.co.uk/2/hi/africa/258446.stm

[4] Jewkes, Rachel; Yandisa Sikweyiya1, Robert Morrell, Kristin Dunkle (2009) UNDERSTANDING MEN’S HEALTH AND USE OF VIOLENCE: INTERFACE OF RAPE AND HIV IN SOUTH AFRICA. South African Medical Research Council.

[5] http://www.rainn.org/statistics/

[6] Tjaden P, Thoennes N. Extent, nature, and consequences of intimate partner violence: findings from the National Violence Against Women Survey. Washington (DC): Department of Justice (US); 2000. Publication No.: NCJ 181867.

[7] http://www.bbc.co.uk/blogs/thereporters/markeaston/2008/07/rape_a_complex_crime.html

In a recent Washington Post article, [Midwife Karen Carr, convicted in Alexandria baby’s death, is under investigation in Md. May 13th] Carr commented, “institutionalization has taken the heart out of health care”. While this may be partly true, we also need to acknowledge that those same institutions provide a critical safety net for mothers and babies who both desire and deserve a satisfying birth experience and good outcomes outside of hospitals.

In that same article, Dr. George Macones (ACOG), made the erroneous statement, that: “The newborn death rate is two to three times higher for planned home births than for those that take place in hospitals”.  Actually, neonatal death is rare in home birth and no more frequent than low risk hospital birth. [1,2,3]

Macones is likely citing a statistic published in his organization’s revised position statement on home birth [4], which utilized a single meta-analysis published by Wax, et al.[5]  As described in a recent Medscape article by five prominent home birth researchers [6], 4 of the 7 studies that were included in the meta-analysis to calculate the neonatal death rate were included inappropriately. These studies did not exclude for planned and unplanned home births and/or did not exclude for congenital birth defects.

Why is ACOG willing to promote unsound evidence as justification for its position of aversion to home birth? Possibly due to sensationalized stories of home births gone wrong or their individual member’s experiences with birth, they cannot believe the large body of evidence from the US, Canada, and Europe that show planned home birth to be safe for mothers and babies.  In a recent conversation I participated in with Dr. Macones and others on NPR’s Kojo Nnamdi show, Dr. Macones said, “it shouldn’t come as a surprise to anyone [that there would be an increased risk to newborns in home birth]“. [7]

Actually, it would be a great surprise to myself, US midwives, international midwives, and even the OB organizations of European Union countries like the UK, all of which are striving to make midwifery and home birth available to more women because of the significant cost savings and excellent outcomes for mothers and babies associated with this model of care. [8,9,10,11]

All maternity care providers, midwives and physicians alike, adhere to the fundamental ethical principles of beneficence, to do good, and non-malfeasance, or do no harm. We all make decisions based on the best evidence available to provide women information about risks and benefits of all options for their care. Though many midwifery advocates would argue that there is a significant body of evidence to show the safety of home birth, US physicians continue to argue that the evidence is outside of the country and therefore irrelevant.  Rather than continue the finger pointing over why things are different for US women, let’s take the next step from the productive conversation that was led by Kojo Nnamde in May. Let’s start talking about what we agree on and start coming up with solutions to identified problems.

Women have the right to choose their provider and place of delivery. Home birth will continue to be a reasonable choice for many mothers and is on the rise in the United States. Midwifery care leads to fewer interventions for mothers.  Fewer interventions like cesarean section, when combined with good outcomes for babies will amount to significant cost savings for everyone. Systems of care that integrate midwifery and medical models will allow for increased choices for women and optimal outcomes. Legislation offering licensure and regulation of CPMs in all 50 states, including Maryland and the District of Columbia, will allow for improved mechanisms of accountability and remove obstacles to communication, collaboration, and integration between physicians, midwives, and the women we all serve.

Citations:

1. Johnson K, Daviss BA.  Outcomes of planned home birth with certified professional mid-wives: large prospective study in North America. BMJ 2005;330;1416.

2.Hutton EK, Reitsma AH, Kaufman K. Outcomes associated with planned home and planned hospital births in low-risk women attended by midwives in Ontario, Canada, 2003-2006: a retrospective cohort study. Birth. 2009;36:180-189.

3.  de Jonge A, van der Goes BY, Ravelli ACJ, et al. Perinatal mortality and morbidity in a nationwide cohort of 529,688 low-risk planned home and hospital births.BJOG. 2009;116:1177-1184.

4.American College of Obstetricians and Gynecologists issues opinion on home births. http://www.acog.org/from_home/publications/press_releases/nr01-20-11.cfm

5.Wax JR, Lucas FL, Lamont M, et al. Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis. Am J Obstet Gynecol 2010;203:243.e1-8.

6.Carl A Michal, PhD, Patricia A Janssen, PhD, Saraswathi Vedam, SciD, Eileen K Hutten, PhD, Ank de Jonge, Phd. Planned Home Birth vs. Hospital Birth: A Meta Analysis Gone Wrong. Medscape Ob Gyn 4/01/2011; http://www.medscape.com/viewarticle/739987

7. Midwifery in Our Region, 5/16/2011. Kojo Nnamdi http://thekojonnamdishow.org/shows/2011-05-16/midwifery-our-region

8.  American College of Nurse-Midwives. The American College of Nurse-Midwives expresses concerns with recent AJOG publication on home birth. Available at: http://www.medscape.com/viewarticle/725382 Accessed March 28, 2011.

9. Simkins G. Letter. RE: Maternal and newborn outcomes in planned home birth vs. planned hospital births: a meta-analysis. July 6, 2010. Available at: http://mana.org/pdfs/MANA-Response-AJOG-Article-7-6-2010.pdf Accessed March 28, 2011.

10. National Association of Certified Professional Midwives. Press release. July 6, 2010. Available at: http://www.nacpm.org/documents/070610-NACPM-Press-Release-Wax-etal.pdf Accessed March 28, 2011.

11. Royal College of Obstetricians and Gynaecologists Position on Home Birth. 1/04/2007. http://www.rcog.org.uk/womens-health/clinical-guidance/home-births

The challenge of the cultural divide continues to be an obstacle to resolution, with both “sides” feeling conflicted. While there are distinct moments of mutual agreement about issues and concerns that come at each meeting, this feeling of movement is tempered by the untenable areas related to patient autonomy and physician supervision. Following the meeting, for which minutes are not yet available, Deren and I sent the following letter to Board of Medicine Executive Director, Dr. William Harp:

Dr. William Harp
Executive Director
Virginia Board of Medicine
Perimeter Center 9960
Mayland Drive, Suite 300.
Henrico Virginia 23233-1463

Date 5/8/11

Dear Dr. Harp,
After our fourth meeting last week it is clear to us, as representatives of the midwifery and home birth community for the Workgroup that an impasse has been reached between medicine and midwifery. There is an obvious and immoveable sentiment among members of the Workgroup who represent the full Board that there will be no endorsement of a plan to allow access to medications for midwifery clients without agreement to restrict access to home birth. Additionally, there is resolute resistance to the concept of drafting model language that would allow the use of medications by any providers who are not supervised by physicians.

Though there was some tentative discussion at the last meeting of issues directly related to access to medications such as protocols and training, the vast majority of our time was spent revisiting the conflicts over standard of care and physician/midwife relationships. Persisting in this dialogue is not productive toward the goal of the Workgroup. As the representatives of Virginia midwives on the workgroup we do not have the blessing or the authority to negotiate issues of midwife autonomy and risk screening. The suggestion by Workgroup members that midwives give up the right to care for women with potential risk factors would likely lead to an increase in unlicensed midwifery practice or unassisted birth. To close one gap in care by opening another one would simply compromise safety in a different way. We cannot see the point in continuing to respond to requests for research. There is no amount of data available that can justify the continued lack of access to basic medications for clients in midwifery care. Neither can we agree that restricting risk factors for home birth will impact the suitability for the use of these medications by well-trained midwives attending births outside the hospital environment.

In order to move forward in a way that justifies the public cost and respects the time and energy of the Workgroup members, we feel that the staff at the Board of Medicine should be directed to draft model statutory language which would outline a mechanism for obtaining, carrying, and administering medications by Licensed Midwives that does not include physician supervision. All of the members of the Workgroup have agreed that supervision is not tenable at this time. Physicians are unwilling to assume liability for the actions of midwives, and therefore midwives are unable to find physicians to supervise them. An autonomous mechanism seems to be the only remaining solution.

As Brynne stated during our last meeting, the midwifery community accepted licensure without access to medications because we knew that practicing with a legal status would increase the safety of home birth and the accountability of the midwife providers in the Commonwealth.

We continue to believe that access to basic emergency and newborn medications would make home birth safer for mothers and babies, but we cannot continue our participation in the workgroup without action and input from staff expertise at the Board of Medicine and an indication that our fellow Workgroup members are committed to helping us solve this problem.

We respect the effort and intention put forth by the Board of Medicine in the creation of this Workgroup. But until a will exists among members of the group and of the full Board to acknowledge the need to move forward with a mechanism for medications without an agreement for practice restriction, we do not believe our efforts are serving the public and we respectfully request that the effort be tabled.

Sincerely yours,

Brynne Potter, CPM and Deren Bader, CPM, DrPH

At this time, we have had no response and a next meeting has not been scheduled.  What are your thoughts on next steps for Virginia midwifery?

The Bottom Line (from physician members of the workgroup):
They’ll give us medications if we agree to restrict access to homebirth for women they believe should not birth at home (ie. no twins, breeches, or VBAC).  You can read about the history on how we came to have the statutory authority to attend these births with informed consent in two previous posts:

Making Lemonade- a recipe to support HB 2163

Evidenced Based…it’s now the law

Our Reaction:
Virginia Midwives will never sacrifice the rights of women to have access to care in the setting and with the provider of their choice.  We will continue to work to educate the Board of Medicine about the issues related to their in-decision on medications and strive to develop a comprehensive model for obtaining medications that addresses as many of the concerns that we can without creating new obstacles or barriers to practice.

Deren and I were appointed to this workgroup to represent the interests of the CPMs. At 3:30am on the day of the meeting, one of our clients woke up in labor. I drew the short straw and went to Richmond for the meeting while Deren and our new assistant midwife, Debbie, stayed here in Charlottesville to be midwives. Even though I had to make the presentation alone, it was nice to be able to anchor myself in the resolve to continue this frustrating work of building relationships with medicine…we do it for women and babies and we won’t stop pushing until midwives have all of the resources they need to provide optimal care for families who birth out of hospital in Virginia.

Next Steps:
The next workgroup meeting date has not been set.  It will be sometime before June, most likely in late April or early May.  Stay tuned for more information.  You can join the Friends of CMA yahoogroup  to stay involved in advocacy efforts with the Commonwealth Midwives Alliance.

About The Author:
Brynne Potter is a Certified Professional Midwife (CPM) who has worked in the field of midwifery since 1991. She is a member of the North American Registry of Midwives (NARM) Board of Directors and a partner at Mountain View Midwives, a midwifery practice in Charlottesville, VA. Brynne is also a co-founder of Private Practice, practice management software for midwives.

If this truly is a battle, then women and babies are the collateral damage. Mothers need to take charge of their own healthcare decisions by designing and managing their own collaborative care and the US government is now giving them to tools to do it.

Many healthcare consumers are creating collaborative care for themselves when they hire multiple providers, like doulas and obstetricians, to support different aspects of the same conditions. They take what they like from each provider and then try to leave the rest behind.  It amounts to a customized “standard of care”.  The US government is now supporting this movement with the adoption of Final Rules from the Dept of Health and Human Resources on Electronic Health Record (EHR) Incentives. Mandates for patient access to their own electronic medical records will put the flow of information directly into the hands of consumers who will then be able to share their health information with multiple providers during the course of their care. No longer will they need the permission of their primary provider (through a request form) to access their records.

The implications of this simple change in “who really owns the information” stand to create ripple effects in the status quo. Despite the clear challenges presented when collaborating providers don’t even know they are collaborating, there are significant benefits to a shift in power from provider to patient. Changes in maternity models will soon be driven by the economics of consumer demand rather than a profession that holds a lock on our current healthcare system through a monopoly on insurance reimbursement and standards of care. When providers stop fighting over the slices of pie, maybe women will stop being unnecessarily cut when they have their babies.

Why Can’t the Maternity Care Providers Work it Out?

Elton says:

Some observers, including Wax, further suggest that American women should draw only limited conclusions about the safety of home birth from studies conducted in other countries. The experience of home birth in the Netherlands, for instance, where 1 out of 4 mothers delivers at home, bears little resemblance to the process most American women endure.

…In the Netherlands, moreover, midwives are fully integrated into the health care system and obstetrics practices, making transfers to hospitals routine. In the U.S., where 1 out of 200 women gives birth at home, midwives can be and have been arrested for bringing their patients to hospitals in states that do not license CPMs.

It is unacceptable for US obstetricians to point to the lack of timely access to hospital care for women choosing to labor at home when those same obstetricians refuse to adopt integrated collaborative systems like those utilized by countries that support out of hospital delivery and have better outcomes in maternity care as a whole.

Melissa Cheyney discusses one of the biggest obstacles to collaboration in her Huffington Post article, Why Home Births are Worth Considering.  She envisions the most important step in improving outcomes in maternity care:

Instead of a maternity system based on fear and misinformation, we need a system based on collaboration and mutual respect.

Cheyney highlights a lack of mutual respect and understanding between midwives and obstetricians as impacting collaboration and transfer of care:

…research has shown deep mistrust between doctors and some midwives. Many doctors have expressed the belief that only hospital births are safe, while midwives say they often feel marginalized and disrespected.

Such studies [e.g. Wax] only deepen this mistrust and have the potential to increase hostility during encounters when midwives and their clients have to seek hospital care for complications. The end result is a system that can be detrimental to women and their babies because of the impaired ability to communicate across a cultural divide.

Peace between providers due to a change in perspective from either side is an unlikely outcome.  As good negotiators know, the best way to mediate any dispute is to find compromises that result in a win for everyone.  Everyone “wins” in the birth battle when women have better outcomes.  It is the result we all want and we have great examples of birth models that work, and what makes for better outcomes is collaboration.

The question remaining is: how will obstetricians and midwives meet the challenge of a newly empowered patient who creates her own collaborative care?

Suzie contemplating her potential…

When President Obama signed part two of the Health Care Reform Legislation [The Health Care and Education Reconciliation Act of 2010 ("Reconciliation Bill")] on March 30th, a provision of the FSLA (Fair Labor Standards Act) was amended to require employers to provide space for working moms who need to express breast milk.

A new paragraph (r) is added to Section 7 of the FLSA that requires employers to provide unpaid, reasonable break time for nursing mothers to express breast milk, as such employee has need to express the milk, for one year after the child’s birth and a place to express the milk “other than a bathroom, that is shielded from view and free from intrusion.” An employer with less than 50 employees will not be required to implement this provision if doing so would cause the employer an “undue hardship.”

This provision is effective immediately.

A great step for healthy babies.

How many of you have pumped milk or nursed your baby in a bathroom?

Mountain View Midwives has moved.  We are no longer nestled in the womb of Brynne’s basement and have emerged into a real, live commercial space.  Our new home at 1111 Rose Hill Drive, Suite #1 has lots of sunshine and some extra space for gathering.  Join our facebook fan page to get news of our planned Open House (May 1!), Yoga Classes, Postpartum Moms Group, Home Birth Meetup, and more.

Not in the opinion of the Commonwealth of Virginia.
As a follow up to last year’s passage of legislation that would require evidence-based informed consent for all women seeking home birth Evidence Based-It’s Now the Law, the Virginia Regulatory Townhall posted the first of two public comment opportunities.
Please read the following open letter to Midwifery Advocates and take a moment to post a comment to the Commonwealth of Virginia regarding your thoughts on informed choice in maternity care.

Dear Midwifery Advocates, Researchers, and Educators -

I am writing on behalf of the Certified Professional Midwives licensed in Virginia to ask for your support involving establishment of regulatory precedent for evidenced-based informed consent for women seeking maternity care.  As some of you may already know, last year the VA General Assembly passed a bill that required CPMs to provided evidenced-based informed disclosure to all women seeking home birth. You can read the history of how this happened here:  http://midwifemonologues.com/making-lemonade-a-recipe-to-support-hb-2163/

Risk factors that were listed in the law included vbac, twins, and breech presentation but also allowed for “other high risk pregnancies”.  The law does not state that these conditions would prohibit CPMs from attending a woman at home, just that the CPM will be required to provide clear, evidence-based informed consent before doing so.

The process that follows a statutory mandate for regulatory change in Virginia is open to the public and participation is simple.  The notice of intended regulatory action (NOIRA) has recently been posted to the Virginia Townhall Website.  The summary and details of the guidelines for this regulatory change are listed in a pdf (here) and there is now a 30 day public comment period.  Comments can be submitted by any member of the public, both in Virginia and outside of the state.

After the comment period ends (11/25/09), a Work Group consisting of members of the Board of Medicine and the midwifery community will convene to come up with a list of conditions that require additional informed choice, and draft specific informed choice documents that will be included in the regulations for CPMs.  These documents will then be presented to the Advisory Board on Midwifery and the full Board of Medicine for review.  There will be a public hearing and then another 30 day public comment period before final approval.

The midwifery community in Virginia believes that even though this requirement is redundant to our existing statutory requirement to practice the Midwives Model of Care, which is based on informed choice, the opportunity to establish once and for all that women are choosing midwifery care and home birth of their own free and informed will, is worthy of our close attention and support.  We believe that if we can engage the Board of Medicine in an unprecedented process of looking at evidence-based criteria for competent practice, we will widen the narrow band of understanding that is forming between medical and midwifery based maternity providers.  In addition, we need to be vigilant during the process to make sure that any guidelines or rules established do not create unforeseen obstacles to care for women who may fall into gray areas regarding relative risk of home or hospital birth based on current standard of practice in many hospital settings.  Mandated c-sections for VBAC, twins, and breech are good examples of the conundrum many midwives and their clients face when providing and making informed decisions for care.

We ask that you review and consider this outlined process and then post a comment to the Townhall Web site.

For those of you with a background or expertise in evidenced-based maternity care, please include your credentials and give citations to your work or other relevant resources that you can provide to the Work Group.  The NOIRA specifically states that the department plans to look to other states with various models of reviewing and determining risk. Item number 3 under “Substance” is especially interesting and invites response:

“If the factors or criteria have been identified that may indicate health risks associated with birth of a child outside a hospital, a requirement for the midwife to provide evidence based information on such risks. Such information would be specified by the Board for certain conditions and would include statements and evidence from both the medical and midwifery models of care.”

It appears that the agency believes that “evidence” is a subjective term and that is why we need evidence from both sides.  While I commend the Agency in its efforts to be fair and balanced, I believe this statement shows how imperative it is that we provide them with clear and objective evidence (research) from which to draft their documents.

For those of you who have used, are utilizing, or intend to use maternity services in Virginia, please tell the Agency what you would like the documents to include.  It is up to you to remind them that you want your informed choice to include the risks and benefits of home birth and that you want your “evidence” to be based on research, not opinion.  It is up to you to ask for information on the risks of hospital or caesarean delivery in certain situations as part of complete informed decision making. It is also up to you to review the current midwifery regulations and comment on any other aspect or restriction involving access to care that you believe should or could be improved.  They are asking for your opinions and this is a great opportunity to give them.

By providing  your comments, you support and engage the process.  You also remind everyone involved that the process is being carefully watched.  Most importantly, your comments may have a ripple effect in creating a future where ALL maternity providers are required to give evidenced-based informed choice to their clients.

Thank you for your time and attention. Please forward this request to anyone in your contact list that you believe would want to have this opportunity to participate in this process. Feel free to contact me with any questions or concerns.

Brynne Potter, CPM

Legislative Policy Coordinator, Commonwealth Midwives Alliance

brynne@mountainviewmidwives.com

www.mountainviewmidwives.com

o: 434-962-0148

m:434-962-5453